Surgery 6 - Questions v1

Exam Section : Item 1 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Surgery Self-Assessment 4 hr 56 min 19 sec
1. A 15-year-old boy is brought to the emergency department by his parents because of a 3-hour history of severe pain in
his right testicle. He has not sustained any recent trauma and has no history of serious illness. His temperature is
37°C (98.6°F), pulse is 72/min, and blood pressure is 110/70 mm Hg. Cardiopulmonary and abdominal examinations
show no abnormalities. The right testicle is high in the right hemiscrotum, transverse, and exquisitely tender to
palpation. The left hemiscrotum is normal. Urinalysis shows no abnormalities. Which of the following is the most
appropriate next step in management?
0 A) Transillumination of the right hemiscrotum
0 B) Application of an ice pack to the right hemiscrotum
0 C) Technetium Tc 99m sestamibi scan of the testes
0 D) Intravenous administration of antibiotics
0 E) Surgical exploration of the scrotum
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2. A 67-year-old man comes to the physician because of a 5-day history of chest pain, fatigue, shortness of breath, and a
nonproductive cough. The chest pain is exacerbated by inspiration or lying down and is relieved when he leans forward .
Three weeks ago, he underwent three-vessel coronary artery bypass grafting. His initial postoperative course was
uncomplicated , and he was discharged 16 days ago. His temperature is 38.2°C (100.8°F), pulse is 85/min and regular,
and respirations are 14/min. The lungs are clear to auscultation. A friction rub is heard best over the left anterior chest.
An x-ray of the chest shows no abnormalities. An ECG is unchanged from the ECG taken on discharge. Which of the
following is the most appropriate next step in diagnosis?
0 A) Echocardiography
0 B) Venous duplex ultrasonography of the lower extremities
0 C) Myocardial biopsy
0 D) Coronary angiography
0 E) Pulmonary angiography
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3. A 37-year-old woman comes to the physician for evaluation of a mole on her left cheek because her uncle was recently
diagnosed with widely metastatic melanoma. She has had the mole for 15 years, and there have been no recent
changes. Examination of the left cheek shows a 0.5-cm, smooth, dome shaped , round , brown papule nevus with distinct
symmetric borders. A 4-mm, smooth, moveable left posterior cervical lymph node is palpated. Which of the following is
the most appropriate next step in diagnosis?
0 A) Observation only
0 B) Biopsy of the inguinal lymph node
0 C) Excisional biopsy of the nevus with a rim of normal skin
0 D) lncisional biopsy of the nevus
0 E) Needle biopsy of the nevus
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4. A 4-year-old boy is brought to the physician because of pain and burning of his right eye after playing in a sandbox.
Although he insists that something is in his eye and he continues to rub it, no foreign body is apparent. He also states
that his vision is blurry in the right eye. There is moderate conjunctiva! injection with marked tearing and photophobia.
The pupils are equal, round, and reactive to light and accommodation. Funduscopic examination shows no
abnormalities. Which of the following is the most appropriate next step in diagnosis?
0 A) Indirect funduscopy
0 B) Measurement of intraocular pressure
0 C) Formal visual field testing
0 D) Gram stain of conjunctiva! fluid
0 E) Conjunctiva! instillation of fluorescein
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5. A previously healthy 42-year-old woman has the abrupt onset of severe headache, followed several hours later by
lethargy and coma. On admission to the hospital, she is unresponsive and has nuchal rigidity; pupillary responses and
corneal and oculocephalic reflexes are intact. She dies the following day. An autopsy is most likely to show which of the
following?
Q A) Fresh subarachnoid hemorrhage at the base of the brain

Q B) Infarct in the left lateral cerebral hemisphere
Q C) Necrotic tumor of the corpus callosum and frontal lobes
Q D) Hemorrhage in the pons and midbrain
Q E) Right epidural hemorrhage
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6. A hospitalized 62-year-old woman has a rash over her lower extremities that
developed 2 days after she underwent emergent left-sided cardiac
catheterization and subsequent angioplasty and stent placement to the left
anterior descending artery. There were no intraoperative complications. She
was admitted because of a 2-hour history of chest pain ; on admission, an initial
ECG showed 3-mm ST elevation in leads V 2 through V 4 . Her temperature is
36.9°C (98.4°F), pulse is 98/min, respirations are 14/min, and blood pressure is
138/78 mm Hg. A photograph of the rash is shown. The posterior tibial and
dorsalis pedis pulses are palpable bilaterally. Which of the following is the most
likely underlying cause of this patient's rash?
0 A) Aortic atheroembolism
O B) Bacterial infection in subcutaneous tissues
0 C) Incompetent venous valves
0 D) Systemic vasculitis
0 E) Thrombocytopenia-induced capillary bleeding
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7. A 60-year-old woman has had left shoulder and arm pain for 2 weeks. She has smoked two packs of cigarettes daily for
35 years. Examination shows a fixed, dilated left pupil and ptosis on the left. X-rays of the chest are shown. Which of the
following is the most likely diagnosis?
0 A) Bronchogenic carcinoma
0 B) Mesothelioma
0 C) Sarcoidosis
0 D) Thymoma
0 E) Tuberculosis
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8. A 62-year-old man comes to the emergency department because of swelling and discomfort of the left foot that began
after digging in his garden 2 weeks ago. There is no history of recent trauma. He has type 2 diabetes mellitus treated
with an oral hypoglycemic agent. His temperature is 37.2°C (99°F), pulse is 74/min, and blood pressure is
150/92 mm Hg. Examination shows a markedly swollen, warm, erythematous left foot. There is no tenderness to
palpation of the foot. Pedal pulses are palpable. Sensation to light touch is intact, and proprioception is decreased.
Range of motion of the left ankle is from 20 degrees of dorsiflexion to 30 degrees of plantar flexion; movement is not
painful. Laboratory studies show:
Hemoglobin 14.5 g/dL
Leukocyte count 11,000/mm3
Erythrocyte sedimentation rate 25 mm/h
Serum glucose 125 mg/dL
X-rays of the left foot show fragmentation and destruction of the midtarsal joints and lateral subluxation of the forefoot.
Which of the following is the most likely underlying mechanism of these findings?
Q A) Immunologically driven synovial proliferation

Q B) Intra-articular precipitation of calcium pyrophosphate crystals
Q C) Intra-articular precipitation of monosodium urate crystals
Q D) Loss of afferent sensory nerve function
Q E) Osteomyelitis
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9. A 4 ?-year-old woman with breast cancer has the sudden onset of confusion and lethargy. Funduscopic examination
shows papilledema. A CT scan of the head shows a cerebellar metastasis. Which of the following is the most
0 A) Corticosteroid therapy
0 B) Anticoagulant therapy
0 C) Vigorous hydration
0 D) Examination of cerebrospinal fluid
0 E) Craniotomy
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Exam Section: Item 10 of 50 National Board of Medical Examiners Time Remaining:
10. A 57-year-old woman is brought to the emergency department after being found comatose. During the past 3 days,
she has been lethargic and somnolent, but she has not had focal neurologic signs. Twelve years ago, she had stage Ill
carcinoma of the right breast treated with a modified radical mastectomy and adjuvant chemotherapy. Eight months
ago, a pulmonary metastasis was diagnosed that has responded well to cytotoxic chemotherapy. Two weeks ago, the
patient underwent a course of radiation therapy to the lumbar spine and iliac crest for painful bony metastases. Which
of the following is the most likely cause of this patient's current symptoms?
0 A) Adverse reaction to cytotoxic chemotherapy
0 B) Cerebral infarction
0 C) Hypercalcemic crisis
0 D) Seizure disorder
0 E) Systemic effect of radiation therapy
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11 . A 57-year-old woman who had tuberculosis many years ago comes to the emergency department because of
hemoptysis that has progressed over the past 6 hours. She is slender but not emaciated. X-rays of the chest show a
3-cm cavity in the left upper lobe of the lung with a round 2-cm mass in its lumen. Which of the following is the most
likely cause of the hemoptysis?
0 A) Adenocarcinoma of the lung
0 B) Aspergilloma
0 C) Histoplasmosis
0 D) Mesothelioma
0 E) Small cell carcinoma of the lung
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12. A 65-year-old man is brought to the emergency department 1 hour after an episode of syncope. He has a 1-day history
of back pain that radiates to his right groin. He has hypertension, chronic back pain, and hypercholesterolemia. His
medications are hydrochlorothiazide, lisinopril , simvastatin, and ibuprofen. He has smoked one pack of cigarettes daily
for 40 years. His temperature is 36.6°C (97.9°F), pulse is 124/min, respirations are 22/min, and blood pressure is
92/54 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Abdominal examination shows diffuse
tenderness with no guarding or rebound. A pulsatile abdominal mass is palpated in the supraumbilical region.
Examination of the back shows no abnormalities. Which of the following is the most appropriate next step in
diagnosis?
0 A) Bedside transabdominal ultrasonography

0 B) CT scan of the abdomen and pelvis with contrast
0 C) HIDAscan
0 D) Intravenous pyelography
0 E) Peritoneal lavage
0 F) Digital subtraction arteriography
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13. A 57-year-old woman with metastatic cancer of the sigmoid colon is admitted to the hospital because of a 2-day history
of progressive swelling and pain of her right arm . Ten days ago, she underwent partial resection of the liver and
placement of a right subclavian venous port. She currently takes no medications. Examination today shows a swollen,
tender right forearm and hand. Venous duplex ultrasonography shows thrombosis of the right axillary and subclavian
veins. The port and catheter are removed, and intravenous unfractionated heparin therapy (UHT) is begun. After
2 days of UHT, the patient's pain has decreased . Laboratory studies on admission and after 2 days of UHT show:
On Admission 2 Days After Admission
Hemoglobin (g/dL) 9.8 9.6
Hematocrit (%) 28 27
Leukocyte count (/mm 3) 8900 12,600
Platelet count (/mm 3) 260,000 61 ,000
Prothrombin time (sec) 12 (INR=1) 13 (INR=1.1)
Partial thromboplastin time (sec) 32 87
Which of the following is the most appropriate next step in management?
0 A) Measurement of antithrombin Ill concentration
0 B) Serum o-dimer assay
0 C) Discontinuation of heparin
0 D) Platelet transfusion
0 E) Thrombolysis
0 F) Warfarin therapy
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14. An 82-year-old man comes to the emergency department because of a 2-day history of extreme difficulty voiding and
urinary incontinence. He has seasonal rhinitis, hypertension , and congestive heart failure. Medications include
diphenhydramine, isosorbide, metoprolol, terazosin , and lisinopril. Vital signs are within normal limits. Examination
shows a moderately enlarged, nontender prostate; no masses are palpated . His postvoid residual volume is 490 ml.
Which of the following medications is most likely contributing to his urinary symptoms?
0 A) Diphenhydramine
0 B) lsosorbide
0 C) Lisinopril
0 D) Metoprolol
0 E) Terazosin
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15. A 55-year-old man has had heel pain and an

associated limp for 1 month. He works as a police
officer and walks most of the day. The pain is most
severe when he first stands up and walks after lying or
sitting. Palpation of the medial plantar surface of the
heel increases the pain. An x-ray of the heel is shown .
Which of the following is the most likely diagnosis?
0 A) Calcaneal stress fracture

0 B) Osteoarthritis
0 C) Peripheral vascular disease
0 D) Plantar fasciitis
0 E) Spinal stenosis
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16. Ten minutes after transfusion of packed red blood cells is begun, a 62-year-old woman has chest pain , shortness of
breath, and the feeling of impending doom. The transfusion is stopped immediately. Her temperature is
38.5°C (101 .3°F), pulse is 90/min , respirations are 20/min, and blood pressure is 110/80 mm Hg. Examination shows
no other abnormalities. Which of the following is the most appropriate next step in diagnosis?
0 A) Direct antiglobulin (Coombs) test
0 B) Duffy antigen test
0 C) Measurement of serum bilirubin concentration
0 D) Measurement of urine hemoglobin concentration
0 E) Measurement of urine myoglobin concentration
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17. A 50-year-old man with chronic constipation has had anal pain after each bowel movement for 2 weeks. He has also
noted a small amount of bright red blood on the toilet tissue. Pain is relieved by sitz baths between bowel movements.
Which of the following is the most likely cause of these symptoms?
0 A) Anal fissure
0 B) Fistula in ano
0 C) Pilonidal cyst
0 D) Squamous cell carcinoma of the anal canal
0 E) Thrombosed external hemorrhoid
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18. Thirty-six hours after hospitalization for treatment of multiple fractures sustained in a motor vehicle collision, a
47-year-old man develops double vision, confusion, and drowsiness. Examination now shows scattered petechiae
over the upper portion of the trunk. Laboratory studies show:
On Admission Now
Hematocrit (%) 50 30
Platelet count (/mm 3) >160,000 >160,000
Serum alcohol (mg/dl) 235 <80
X-rays of the chest and an ECG on admission showed no abnormalities. An x-ray of the chest now shows diffuse
patchy infiltrates. Which of the following is the most likely diagnosis?
0 A) Aspiration pneumonitis
0 B) Delirium tremens
0 C) Fat embolism
0 D) Myocardial infarction
0 E) Pulmonary embolism
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19. A 57-year-old woman has a decreased urine output (15 ml/h) 2 hours after undergoing a radical hysterectomy for
endometrial cancer; the urine is dark yellow. The operation lasted 4 hours, and her blood pressure decreased to
70/50 mm Hg briefly during the operation. She received 3 L of lactated Ringer solution and 2 units of packed red blood
cells intraoperatively. She has no history of diabetes mellitus or chronic renal insufficiency. Her pulse is 110/min,
respirations are 14/min, and blood pressure now is 100/70 mm Hg. The lungs are clear to auscultation. There is no
abdominal distention. Which of the following is the most likely cause of the oliguria?
0 A) Anesthesia-induced tubular injury
0 B) Decreased renal blood flow
0 C) Obstruction of bladder drainage
0 D) Tubular hemoglobin deposition
0 E) Ureteral obstruction
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20. A 38-year-old man who had been receiving corticosteroids for asthma has an emergency appendectomy for a ruptured
appendix. In the recovery room, he becomes confused and febrile ; his blood pressure is 85/60 mm Hg, and his pulse
is 130/min. Arterial blood gases are normal. His blood pressure does not respond to infusion of 1 L of lactated Ringer
solution. Which of the following is the most appropriate next step in management?
0 A) Administration of hydrocortisone, 100 mg intravenously
0 B) Administration of whole blood, 500 ml
0 C) ECG
0 D) Pulmonary angiography
0 E) Reexploration of the abdomen
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21 . A 35-year-old woman has newly diagnosed pancreatitis. Physical examination shows fibrocystic changes of the
breasts. Serum studies show:
Ca 2+ 12 mg/dl
Phosphorus 1.0 mg/dl
Cholesterol 250 mg/dl
Triglycerides 120 mg/dl
Urinalysis shows hematuria and a urinary pH of 4.5. An x-ray of the abdomen shows a 4-mm calcification in the right
upper quadrant. An x-ray of the chest is normal. Which of the following is the most likely cause of her condition?
0 A) Hyperlipoproteinemia
0 B) Metastatic breast cancer
0 C) Parathyroid adenoma
0 D) Renal tubular acidosis
0 E) Sarcoidosis
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22. A 52-year-old man with type 1 diabetes mellitus comes to the physician for a follow-up examination. Three years ago,
he underwent a cadaveric left renal transplant for diabetic nephropathy. He has been compliant with treatment, and his
immunosuppressive regimen includes prednisone and cyclosporine. He takes lisinopril for hypertension. His
temperature is 37°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 128/82 mm Hg.
Examination shows moderate pedal edema bilaterally and a tender 10-cm mass in the left iliac fossa. His serum
creatinine concentration has increased from 1.9 mg/dl over the past year to 2. 7 mg/dl. Which of the following is the
most likely cause of the renal insufficiency?
0 A) Chronic cyclosporine toxicity

0 B) Chronic rejection
0 C) Hemolytic-uremic syndrome
0 D) Pyelonephritis
0 E) Ureteral obstruction
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23. An 82-year-old man comes to the physician because of a growth on his face for 6 months. It bleeds easily when
touched. He worked as a mail carrier for 42 years. There is a nodule with prominent telangiectasias on the forehead.
0 A) Basal cell carcinoma
0 B) Hordeolum
0 C) Malignant melanoma
0 D) Merkel cell carcinoma
0 E) Squamous cell carcinoma
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24. A 72-year-old man with esophageal adenocarcinoma comes to the physician for evaluation 2 weeks prior to a
scheduled subtotal esophagectomy. He has a 20-year history of gastroesophageal reflux disease treated most
recently with a proton pump inhibitor and a 10-year history of hypertension well controlled with a 13-adrenergic blocking
agent and an ACE inhibitor. He does not smoke or drink alcohol. He is 178 cm (5 ft 10 in) tall and weighs
127 kg (280 lb); BMI is 40 kg/m 2. His blood pressure today is 145/84 mm Hg. Examination shows varicose veins of the
lower extremities with no tenderness. There is 1+ pitting pedal edema. In addition to early ambulation, which of the
following is the most appropriate preventive measure for this patient perioperatively?
0 A) Aspirin therapy
0 B) Clopidogrel therapy
0 C) Low-molecular-weight heparin therapy
0 D) Placement of an inferior vena cava filter
0 E) No other preventive measures are indicated
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25. One hour after delivery at term, a 3750-g (8-lb 4-oz) female newborn begins to choke, cough, and regurgitate while
attempting to breast-feed. Pregnancy and delivery were uncomplicated. Apgar scores were 9 and 10 at 1 and
5 minutes, respectively. Examination shows no abnormalities except for drooling. Which of the following is the most
appropriate next step in diagnosis?
0 A) Barium swallow
0 B) CT scan of the chest
0 C) Flexible esophagogastroduodenoscopy
0 D) Rigid esophagoscopy
0 E) Insertion of a nasogastric tube
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26. A previously healthy 37-year-old woman comes to the physician because of a persistent headache for 1 week with
occasional episodes of nausea when the pain is most severe. She has had no other neurologic symptoms. Use of
nonsteroidal anti-inflammatory drugs has provided no relief. She has smoked one pack of cigarettes daily for 20 years.
Her last pregnancy 3 years ago was uncomplicated. Her last menstrual period was 2 weeks ago. Her pulse is 72/min ,
respirations are 14/min, and blood pressure is 170/120 mm Hg. Examination shows no abnormalities except for mild
papilledema and a right carotid bruit. A renal artery duplex scan shows stenosis of the right renal artery, and a carotid
duplex scan shows 25% stenosis of the right carotid. Which of the following is the most likely cause of this patient's
hypertension?
0 A) Congenital renal artery disease

0 B) Fibromuscular dysplasia of the renal artery
0 C) Premature atherosclerosis
0 D) Undiagnosed previous renal trauma
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27. A 67-year-old woman with essential hypertension comes to the physician because of a 6-month history of moderate
aching of her left arm when she carries grocery bags, does anything with the arm raised above her head, or lifts
anything heavy. One week ago, while cleaning a large mirror, she felt dizzy and almost lost consciousness. She has
not had chest pain, shortness of breath, or sweating. She is left-hand dominant. She takes no medications. She has
smoked one pack of cigarettes daily for 40 years. Her pulse is 72/min and regular, and blood pressure in the left upper
extremity is 115/85 mm Hg. Upper extremity pulses are normal. Muscle strength and sensation testing in the upper
extremities shows no abnormalities. Which of the following additional components of the physical examination is most
likely to confirm the diagnosis?
0 A) Blood pressure measurement of the right upper extremity

0 B) Cardiac auscultation
0 C) Hyperabduction maneuver
0 D) Neck auscultation
0 E) Percussion of the left ulnar nerve
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■ Mark Surgery Self-Assessment 4 hr 54 min O sec
28. A 47-year-old woman is brought to the emergency department 30 minutes after being found unresponsive by her
husband on the bathroom floor. Yesterday, she called the physician after noticing a small scratch on her left labium
majus and received a prescription for levofloxacin. Her husband reports that she has had a 24-hour history of
progressive vulvar redness, hardness, and swelling that spread to her left upper thigh and lower abdomen. She has
type 1 diabetes mellitus. She is responsive to painful stimuli only. Her temperature is 37.2°C (99°F), pulse is 130/min,
respirations are 30/min, and blood pressure is 70/40 mm Hg. Examination shows erythema of the lower abdomen to
the level of the umbilicus and from the left thigh to the knee; there is no crepitus. Pelvic examination shows a purulent
discharge from an open laceration on the left labium majus and marked edema of the labia majora. Emergency
debridement is performed. During the procedure, there is liquefaction necrosis of the subcutaneous tissue, fascia, and
muscle. Which of the following is the most likely causal organism?
0 A) Bacteroides fragi/is
0 B) Candida albicans
0 C) C/ostridium perfringens
0 D) Pseudomonas aeruginosa
0 E) Streptococcus pyogenes (group A)
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29. A 25-year-old woman has a 2-year history of episodic bloody diarrhea, sometimes productive of blood and mucus
without stool, ranging up to 25 anal discharges daily. Examination shows no abnormalities. X-rays of the intestines
show generalized changes in the colon, including decreased size, shortening and narrowing of the lumen , and loss of
haustral markings. Results of an endoscopic biopsy of the colon show mucosal microabscesses. This patient is at
greatest risk for which of the following subsequent conditions?
0 A) Cancer of the colon

0 B) Colonic polyps
0 C) Diverticulosis
0 D) lschemic colitis
0 E) Ovarian cancer
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30. A previously healthy 47-year-old man comes to the emergency department 2 hours after the sudden onset of constant,
severe epigastric pain . He says that the pain feels as if he had been kicked in the abdomen. He appears diaphoretic.
His temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 24/min, and blood pressure is 100/60 mm Hg.
Abdominal examination shows exquisite tenderness and board-like rigidity of the epigastrium and right upper
quadrant. Laboratory studies show:
Leukocyte count 11,900/mm3
Serum
Amylase 140 U/L
Lipase 50 U/L (N=14-280)
0 A) Acute cholangitis
0 B) Acute cholecystitis
0 C) Acute diverticulitis
0 D) Acute pancreatitis
0 E) Acute pyelonephritis
Q F) Gastroesophageal reflux disease
Q G) Mallory-Weiss syndrome
Q H) Perforated duodenal ulcer
0 I) Ruptured esophagus
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31 . Three days after an exploratory laparotomy for a stab wound to the abdomen, a 14-year-old boy has jaundice. He
recently immigrated to the USA from the Caribbean Islands. During the operation, three small enterotomies caused by
the knife were repaired. Multiple long tubular structures, thought to be roundworms (Ascaris /umbricoides), were felt
within the lumen of the bowel; they were not removed . He required 2 units of packed red blood cells intraoperatively.
Examination shows scleral icterus. The abdomen is mildly distended and nontender. Laboratory studies show:
Leukocyte count 10,500/mm 3
Serum
Bilirubin
Total 3.5 mg/dL
Direct 2.9 mg/dL
Alkaline phosphatase 210 U/L
AST 40 U/L
ALT 55 U/L
Which of the following is the most likely mechanism of this patient's jaundice?
0 A) Bile duct obstruction from migrating worms

0 B) Hemolytic anemia
0 C) Hepatitis C
0 D) Resorption of an old hematoma
0 E) Transfusion reaction
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32. A 36-year-old man comes to the physician because of a 4-day history of bloody diarrhea. He has a 16-year history of
ulcerative colitis treated with corticosteroid therapy. His temperature is 37.5°C (99.5°F), pulse is 110/min, respirations
are 16/min, and blood pressure is 124/78 mm Hg. The abdomen is soft and mildly distended; there is mild, diffuse
tenderness to palpation but no rigidity or guarding. Colon contrast studies show a constricting, apple-core,
nonobstructing sigmoid mass. Which of the following is the most appropriate next step in management?
0 A) Antibiotic therapy and bowel rest

0 B) Proctocolectomy
0 C) Radiation therapy
0 D) Segmental colectomy
0 E) Total parenteral nutrition
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33. A 20-year-old man is brought to the emergency department 30 minutes after being involved in a motor vehicle
collision. He was an unrestrained front-seat passenger during the head-on collision. The left lower extremity is flexed
at the hip, shortened, adducted, and internally rotated. He is unable to dorsiflex the ankle. Which of the following is the
most likely diagnosis?
0 A) Acute hemarthrosis
0 B) Femoral neck fracture
0 C) Femoral nerve contusion
0 D) Gluteus medius tendon rupture
0 E) Hip dislocation
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34. A 52-year-old man comes to the physician 3 weeks after an episode of dysphagia while eating meat. He has had
heartburn for 2 years; it has been unrelieved by antacids for 9 months. He has smoked two packs of cigarettes daily
for 35 years. Examination shows no abnormalities. Hematocrit is 36%. A blood smear shows microcytic, hypochromic
erythrocytes. Upper gastrointestinal endoscopy shows erythema of the mucosa between a hiatus hernia and the
midesophagus, with multiple linear erosions. Which of the following is the most appropriate pharmacotherapy?
0 A) Aluminum hydroxide-alginic acid (Gaviscon)

0 B) Bethanechol
0 C) Metoclopramide
0 D) Omeprazole
0 E) Sucralfate
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35. A 55-year-old man is admitted to the hospital because of progressively severe anginal pain secondary to coronary
insufficiency. Coronary artery bypass grafting is scheduled, and the advantages and disadvantages of the procedure
and all relevant details are carefully explained . The patient indicates that he understands what he has been told,
including the risks, and he signs the hospital's consent form. In the operating room holding area, he develops an
adverse reaction to the premedication, and he becomes acutely confused and agitated . He tells the nurse that he is
too frightened to allow the operation and demands that it be canceled. Which of the following is the most appropriate
course of action?
Q A) Cancel the operation

Q B) Proceed with the operation based on the patient's informed consent
Q C) Proceed with the operation only if a new consent form is signed by the patient immediately
Q D) Proceed with the operation only if the family provides informed consent
Q E) Request a psychiatric consultation to assess the patient's mental competence
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36. A 42-year-old woman, gravida 3, para 3, is brought to the emergency department because of severe abdominal pain
that awoke her from sleep 8 hours ago. She had one similar episode 3 months ago that resolved without treatment.
Her temperature is 37°C (98.6°F). Abdominal examination shows right upper quadrant guarding and normal bowel
sounds. Hemoglobin concentration is 12 g/dl, leukocyte count is 12,000/mm 3, and total serum bilirubin concentration
is 1.1 mg/dl. X-rays of the abdomen show no abnormalities. Which of the following is the most appropriate next step
in diagnosis?
0 A) Abdominal ultrasonography
0 B) Angiography
0 C) Aortography
0 D) Barium swallow
0 E) Celiotomy
Q F) CT scan of the abdomen
Q G) Diagnostic laparoscopy
Q H) Endoscopic retrograde cholangiopancreatography
0 I) Endoscopy
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37. An asymptomatic 72-year-old woman comes to the physician for a routine health maintenance examination. Her pulse
is 76/min, respirations are 18/min, and blood pressure is 134/90 mm Hg. Examination shows no abnormalities. Her
hematocrit is 35%. Erythrocyte indices show microcytic anemia. Test of the stool for occult blood is positive. Which of
the following is the most likely cause of this patient's anemia?
0 A) Cecal malignancy
0 B) Hemorrhoids
0 C) Meckel diverticulum
0 D) Peptic ulcer
0 E) Small-bowel malignancy
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38. Eight months after undergoing an abdominoperineal resection of the rectum for adenocarcinoma, a 62-year-old man
has a pelvic tumor and hepatic metastases. He has a poor appetite. He is given sustained-release morphine, orally, to
control pain. Two weeks later he has a fecal impaction in the colostomy area. To prevent recurrence of this condition,
which of the following is the most appropriate next step in management?
Q A) Maintain the dose of morphine and advise the patient to increase intake of fluids
Q B) Maintain the dose of morphine and initiate a daily regimen of oral cathartics and stool softeners
Q C) Decrease the dose of morphine to allow normal evacuation of the bowels
Q D) Discontinue the morphine and begin hydromorphone therapy
Q E) Discontinue the morphine and begin nonsteroidal analgesic therapy
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39. A previously healthy 27-year-old woman is brought to the emergency department because of a 3-hour history of
increasingly severe lower abdominal pain. The pain involves the left side and radiates to the back. Her temperature is
38°C (100.4°F). Examination shows an 8-cm, exquisitely tender ovarian mass. A pregnancy test is negative. Her
leukocyte count is 10,400/mm 3_ Ultrasonography confirms the mass. Which of the following is the most appropriate
next step in management?
0 A) MRI of the pelvis

0 B) Ceftriaxone and doxycycline therapy
0 C) Ibuprofen therapy
0 D) Oral contraceptive therapy
0 E) Laparoscopy
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40. A previously healthy 42-year-old woman is admitted to the hospital for treatment of acute biliary pancreatitis. On
hospital day 5, she is passing flatus occasionally, but she has not had a bowel movement for 3 days. She has loss of
appetite but does not have nausea. Her current medications are a patient-controlled morphine pump and intravenous
omeprazole. Her temperature is 38.5°C (101 .3°F), pulse is 80/min, respirations are 20/min, and blood pressure is
130/75 mm Hg. Abdominal examination shows mild tenderness in the epigastrium and central abdomen to direct
palpation; there is no rebound. A central venous catheter is inserted, and total parenteral nutrition is begun. On
hospital day 6, serum studies show:
Na+ 135 mEq/L
K+ 4 mEq/L
cI - 102 mEq/L
Hco3- 26 mEq/L
Mg 2+ 1.6 mEq/L
Ca 2+ 8.6 mg/dL
Phosphorus 2 mg/dL
Which of the following is the most likely explanation for these laboratory findings?
0 A) Adynamic ileus
0 B) Choledocholithiasis
0 C) Hyperparathyroidism
0 D) Pancreatic exocrine insufficiency
0 E) Refeeding syndrome
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41 . A 63-year-old man has a 3-month history of painless hematuria. Cystoscopy shows a superficial small tumor of the
bladder. A biopsy specimen shows well-defined transitional cell carcinoma in situ . Which of the following is the most
appropriate treatment?
0 A) Bladder irrigation with dimethyl sulfoxide
0 B) Radiation
0 C) Endoscopic resection
0 D) Partial cystectomy
0 E) Total cystectomy
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42. A 42-year-old woman has had fatigue, exertional dyspnea, and palpitations for 4 months. She has a history of frequent
respiratory infections. Her pulse is 90/min and regular, and blood pressure is 120/80 mm Hg. A prominent right
ventricular impulse, wide fixed splitting of S 2, and a systolic ejection murmur are heard. An ECG shows incomplete
right bundle branch block. An x-ray of the chest shows right ventricular enlargement, prominence of the main
pulmonary artery, and increased pulmonary artery markings. Which of the following is the most likely diagnosis?
0 A) Aortic stenosis
0 B) Atrial septal defect
0 C) Coarctation of the aorta
0 D) Patent ductus arteriosus
0 E) Pulmonic stenosis
Q F) Tetralogy of Fallot
Q G) Transposition of the great arteries
Q H) Truncus arteriosus
0 I) Ventricular septal defect
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43. A 42-year-old woman comes to the physician after finding a mass in her left breast on breast self-examination. She
has no history of serious illness and takes no medications. Examination of the left breast shows a 3.5-cm mass with
regular borders in the upper outer quadrant. Aspiration of the mass shows a clear brown fluid. Which of the following is
the most likely diagnosis?
0 A) Carcinoma
0 B) Fibroadenoma
0 C) Fibrocystic disease
0 D) Galactocele
0 E) Paget disease
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44. A 27-year-old man undergoes Roux-en-Y gastric bypass for morbid obesity. He has type 2 diabetes mellitus,
hypertension, and sleep apnea. Twelve hours after the operation, he is awake and alert. He is 175 cm (5 ft 9 in) tall
and weighs 139 kg (305 lb); BMI is 45 kg/m 2. His temperature is 38.1°C (100.6°F), pulse is 90/min, respirations are
10/min, and blood pressure is 145/85 mm Hg. Breath sounds are heard bilaterally with decreased air movement.
Arterial blood gas analysis on 4 Umin of oxygen via nasal cannula shows:
7.31
55 mm Hg
64 mm Hg
26 mEq/L
Which of the following is the most appropriate next step in management?
0 A) Application of continuous positive airway pressure

0 B) Switching from nasal cannula to face mask
0 C) Bronchodilator therapy
0 D) Naloxone therapy
0 E) Reintubation
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45. A 92-year-old woman is brought to the emergency department 6 hours after the
sudden onset of abdominal pain, distention, and vomiting. She has not passed
flatus during this period. She underwent appendectomy 46 years ago.
Abdominal examination shows distention and diffuse tenderness. Bowel sounds
are increased. An x-ray of the abdomen is shown. Which of the following is the
most likely explanation for these findings?
0 A) Adhesions
Q B) Appendiceal phlegmon
Q C) Gallstone ileus
0 D) Intussusception
0 E) Primary tumor of the small intestine
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46. A 49-year-old man with type 1 diabetes mellitus remains hospitalized 2 days after admission for management of
gangrene of the second toe of the left foot. He also has peripheral neuropathy, retinopathy, and stage Ill chronic kidney
disease. His preadmission medications are insulin, valsartan, ramipril, gabapentin, and omeprazole. On admission,
intravenous piperacillin-tazobactam was added to the regimen. He is following a consistent carbohydrate diet. His
temperature is 37.2°C (99°F), pulse is 72/min and regular, and blood pressure is 140/90 mm Hg. Examination shows
dry gangrene over the distal phalanx of the left second toe with minimal residual erythema. Pedal pulses are not
palpable. Ankle systolic pressures are greater than 220 mm Hg bilaterally. Laboratory studies show:
Hemoglobin A 1c 8%
Leukocyte count 8700/mm 3 with a normal differential
Serum
Glucose 160 mg/dL
Creatinine 1.8 mg/dL
On duplex ultrasonography of the left lower extremity, the femoral and popliteal arteries appear normal; there is
occlusion of all three tibial arteries in the proximal calf and reconstitution of the posterior tibial artery just proximal to
the ankle. In addition to continued piperacillin-tazobactam therapy and foot care, which of the following is the most
0 A) Below-the-knee amputation
0 B) Femorotibial bypass grafting
0 C) High-dose clopidogrel therapy
0 D) Percutaneous tibial angioplasty
0 E) Supervised exercise program
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47. A 72-year-old man is admitted to the hospital because of hematochezia for 12 hours. He has mild chronic obstructive
pulmonary disease and osteoarthritis. He sustained a myocardial infarction 4 months ago. Medications include
propranolol and nitroglycerin. His temperature is 36.9°C (98.4°F), pulse is 102/min, and blood pressure is
144/82 mm Hg. Abdominal examination shows no abnormalities. Rectal examination shows dark blood and clots. His
hematocrit is 32%. The bleeding resolves spontaneously 6 hours after admission. Colonoscopy shows a short
segment of sigmoid colon with edema, ulceration, and friability; no other abnormalities are noted . Which of the
0 A) C/ostridium difficile colitis

0 B) Cytomegalovirus colitis
0 C) Diverticulitis
0 D) lschemic colitis
0 E) Ulcerative colitis
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48. A hospitalized 37-year-old woman with type 1 diabetes mellitus and chronic renal failure has the sudden onset of
shortness of breath. Twenty minutes ago, she underwent placement of a right subclavian catheter for hemodialysis
after several unsuccessful attempts to insert a right internal jugular catheter. Her pulse is 120/min, respirations are
32/min, and blood pressure is 90/50 mm Hg. Examination shows no jugular venous distention. Breath sounds are
decreased on the right. Heart sounds are normal. Pulse oximetry on 4 L/min of oxygen via nasal cannula shows an
oxygen saturation of 65% . Which of the following is the most appropriate next step?
0 A) Arterial blood gas analysis
0 B) X-ray of the chest
0 C) Echocardiography
0 D) CT scan of the chest
0 E) Radionuclide lung scan

Q F) Needle aspiration of the right chest
Q G) Pulmonary angiography
Q H) Pulmonary artery catheterization
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49. A 62-year-old man comes to the physician because of a 1-year history of pain in his calves and thighs after he walks
more than two blocks. The pain is relieved after he rests for 5 to 10 minutes. He has smoked one and a half packs of
cigarettes daily for 30 years. His temperature is 37°C (98.6°F), pulse is 75/min, respirations are 16/min, and blood
pressure is 140/80 mm Hg. Examination shows decreased femoral, popliteal, and pedal pulses bilaterally. Which of the
0 A) Aortoiliac occlusive disease (Leriche syndrome)

0 B) Bilateral iliac aneurysms
0 C) Bilateral superficial femoral artery occlusions
0 D) Coarctation of the aorta
0 E) Internal iliac artery stenosis
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50. A 32-year-old male firefighter is brought to the emergency department after being rescued from a burning building. On
arrival, he appears anxious. He is hoarse and coughs up carbonaceous sputum, but his breathing is spontaneous. His
temperature is 38°C (100.4 °F), pulse is 100/min and regular, respirations are 24/min, and blood pressure is
140/95 mm Hg. Pulse oximetry on 40% oxygen by face mask shows an oxygen saturation of 94%. Examination shows
burnt scalp and facial hair. The lips are not cyanotic or cherry red. There are second-degree burns over the face and
neck and third-degree burns over the upper extremities. On pulmonary examination, no stridor is heard. The
remainder of the examination shows no abnormalities. A CT scan of the chest and abdomen shows no body cavity
injuries. Direct laryngoscopy shows pharyngeal edema and erythema. In addition to continued supplemental oxygen
by face mask, which of the following is the most appropriate next step in management of this patient's airway?
Q A) Observation only
Q B) Inhaled corticosteroid and epinephrine therapy
Q C) Intravenous corticosteroid therapy and intermittent positive pressure breathing
Q D) Transoral endotracheal intubation
Q E) Tracheostomy
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Surgery 6 - Questions v1

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Surgery 6 - Questions v1

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Exam Section : Item 1 of 50 National Board of Medical Examiners Time Remaining:

■ Mark Surgery Self-Assessment 4 hr 56 min 19 sec

0 A) Transillumination of the right hemiscrotum

0 B) Application of an ice pack to the right hemiscrotum

0 C) Technetium Tc 99m sestamibi scan of the testes

0 D) Intravenous administration of antibiotics

0 E) Surgical exploration of the scrotum

0 C) Excisional biopsy of the nevus with a rim of normal skin

0 D) lncisional biopsy of the nevus

0 E) Needle biopsy of the nevus

0 C) Formal visual field testing

0 D) Gram stain of conjunctiva! fluid

0 E) Conjunctiva! instillation of fluorescein

Q A) Fresh subarachnoid hemorrhage at the base of the brain

Q A) Immunologically driven synovial proliferation

0 D) Examination of cerebrospinal fluid

0 A) Adverse reaction to cytotoxic chemotherapy

0 E) Systemic effect of radiation therapy

0 A) Adenocarcinoma of the lung

0 E) Small cell carcinoma of the lung

0 A) Bedside transabdominal ultrasonography

0 F) Digital subtraction arteriography

Which of the following is the most appropriate next step in management?

0 A) Measurement of antithrombin Ill concentration

0 B) Serum o-dimer assay

15. A 55-year-old man has had heel pain and an

0 A) Calcaneal stress fracture

0 C) Peripheral vascular disease

0 A) Direct antiglobulin (Coombs) test

0 B) Duffy antigen test

0 C) Measurement of serum bilirubin concentration

0 D) Measurement of urine hemoglobin concentration

0 E) Measurement of urine myoglobin concentration

0 D) Squamous cell carcinoma of the anal canal

0 E) Thrombosed external hemorrhoid

0 A) Anesthesia-induced tubular injury

0 B) Decreased renal blood flow

0 C) Obstruction of bladder drainage

0 D) Tubular hemoglobin deposition

0 A) Administration of hydrocortisone, 100 mg intravenously

0 B) Administration of whole blood, 500 ml

0 E) Reexploration of the abdomen

0 D) Renal tubular acidosis

0 A) Chronic cyclosporine toxicity

0 A) Basal cell carcinoma

0 D) Merkel cell carcinoma

0 E) Squamous cell carcinoma

0 C) Low-molecular-weight heparin therapy

0 D) Placement of an inferior vena cava filter

0 E) No other preventive measures are indicated

0 B) CT scan of the chest

0 E) Insertion of a nasogastric tube

0 A) Congenital renal artery disease

0 D) Undiagnosed previous renal trauma

0 A) Blood pressure measurement of the right upper extremity

0 E) Percussion of the left ulnar nerve

0 E) Streptococcus pyogenes (group A)

0 A) Cancer of the colon

Which of the following is the most likely diagnosis?

0 A) Bile duct obstruction from migrating worms

0 D) Resorption of an old hematoma

0 A) Antibiotic therapy and bowel rest

0 E) Total parenteral nutrition

0 B) Femoral neck fracture